Realities of A New Payment System From the Physician & HOPD Perspective

The Physician’s Perspective (By Lee C. Ruotsi)

“Work harder, see more patients, and conduct more procedures.” — This has long been the mantra when the goal has been driving up revenue in order to have a more successful practice or hospital-based outpatient department (HOPD). Not so anymore! “We have to start to see our practices and outpatient centers as ‘cost centers’ rather than revenue centers,” according to Michael Edbauer, DO, chief executive officer of Catholic Medical Partners, a 1,000-plus member independent practice association at Catholic Health, Buffalo, NY.  Dr. Edbauer stands at the helm of what’s been one of the top-performing accountable care organizations in the country over the past several years. Several months ago, this author met with Dr. Edbauer to discuss how the upcoming changes in the healthcare payment paradigm might affect the three HOPDs for which this author provides medical directorship. As an overreaching concept, we must first understand the notion of the “Triple Aim” as put forth by the Institute for Healthcare Improvement, which is to: 1) improve the patient experience of care; 2) improve the health of populations; and 3) reduce the per capita cost of healthcare.¹ 

What this translates to, for all wound care physicians, is a need to “work smarter, not harder,” and to no longer choose expensive products and treatment modalities just “because we can.” Dr. Edbauer also described how, in years to come, primary care physicians (ie, our referral base) will need to manage their referrals based not only on quality of care and preexisting relationships, but also the cost at which that subspecialty care is delivered. Simply stated, this means that if the wound center “down the street” is providing similar quality care for a lower cost, there will be a financial disincentive for referring physicians to continue to refer to one’s program. Remember, too, that patient satisfaction scores will also be a part of what is measured and will be prominently displayed on referring physicians’ radar screens. 

All of what has been described here reflects the overall shift from the first curve of healthcare economics to the second curve. The first curve was and is a volume-based, fee-for-service system in which there is no reward for high quality and no shared financial risk between the provider and the healthcare system. The second curve is a value-based system in which payment rewards population value, quality, and efficiency, and there are partnerships with shared risk – all while acknowledging the demographics and increased severity of the patients we care for. Additionally, we are all aware of the mandates set forth by the Merit-Based Incentive Payment System (MIPS) and the Medicare Access and CHIP Reauthorization Act (MACRA) that will be implemented in 2019.²

A key feature to all of this will be the relationship between the wound care physician and the HOPD. In the presently common scenario in which the physician is an independent contractor who bills separately for professional components of services, financial risk-sharing will be more challenging, potentially making this model increasingly unattractive to hospital systems and physicians alike. The employment model, however, in which the wound care physician is paid on either a salaried or hourly basis, will allow mutually beneficial risk-sharing and potential incentives for top-performing physician and non-physician providers. Certainly, there will be scenarios in which the independent contractor model will continue to be viable; however, present trends seem to be moving more toward the employed physician model. If you’re thinking, “We’re going to lose more control and autonomy over our practice patterns,” you’re correct! We’re going to have to improve our bottom lines by practicing better, more efficient wound care rather than relying on increased numbers of procedures and product-application incentives. A $200 application fee for a five-minute outpatient application procedure … really? Dr. Edbauer points out that the Centers for Medicare & Medicaid Services (CMS), as well as commercial insurance carriers, will have all physician and non-physician providers on a bell-shaped curve.  This curve will be based on the aforementioned metrics of quality, cost, and patient experience, and our referral base will have access to (and be expected to make) their referrals based on the top-performing providers, with clear disincentives for referrals to the outliers. Despite that there will likely continue to be enough wound care business to go around, the new paradigm will result in keener competition among programs and providers based on these factors. Please, don’t shoot the messenger!

The End Result

So, what will this all translate to in our practices? First and foremost, it’s clear that many of our more expensive treatment modalities and products have excellent evidence-based and literature support, and most certainly will remain important components of our wound care armamentarium — especially in our more challenging patients. Further, some of these products will ideally be used sooner in the course of treatment, when wound conditions and patient-related factors dictate that conservative measures will not be sufficient. What it means is that we will have to prescribe hyperbaric oxygen therapy (HBOT) based on clinical and objective indicators that predict those patients who will have the greatest likelihood of deriving benefit while consciously avoiding unnecessary, wasteful, and/or futile HBOT. We will have to utilize cellular and tissue-based products (CTPs) based on the similarly aforementioned criteria for HBOT while carefully avoiding their use in patients who would have healed expeditiously with high-quality conservative care. We will need to be thoughtful about our approach to debridements.  While it’s well established that wounds that are debrided in an appropriate, timely fashion heal more quickly, it’s likewise true that not all wounds require a subcutaneous level of debridement every week. In fact, there are Medicare intermediaries who already have draft documents in place that would limit debridements to eight per year. We will need to pay close attention to important and well-thought-out quality measures in wound care.³ We will need to revisit the basics, such as meaningful offloading for diabetic foot ulcers and proficiently applied multilayer compression wrapping for venous leg ulcers, along with timely and appropriate workups for infection, arterial supply, and venous reflux.  In short, we will need to choose our advanced products and modalities not “because we can,” but because “it’s the right thing to do.” Musician Bob Dylan once said, “The times, they are a-changin.’” The Greek philosopher Heraclitus said long before him, “The only constant in life is change.” Healthcare is no different.  As we move closer to the 2019 implementation of MIPS and MACRA, we must maintain a razor-sharp focus on what quality wound care practice really means. At the end of the day, better clinical care, with a better patient experience, delivered in a cost-effective fashion is really just better care. I recall hearing the saying, “If you still think OSHA is a small town in Wisconsin, you’re in trouble” back in the 1980s. I would update this sentiment for the modern wound care physician by saying, “If you still think MIPS and MACRA are some offbeat computer language, you’re in trouble.” 

The HOPD’s Perspective (By Dot Weir)

I began working in a wound care HOPD in 2001, when life was much more simple. The number of advanced modalities available could literally be counted on one hand: There was negative pressure wound therapy; two “skin substitutes” (as we called them back then) that could be placed outside of the operating room; a platelet-derived growth factor gel (still the only one available); and collagen as an advanced dressing was gaining use as other collagen and matrix products were coming to the marketplace. The realization of the need to reduce the use of topical antibiotics gave way to the use of more antimicrobial dressings, and, at that time, there was only one clinic in the region that provided HBOT. We utilized both Unna’s boots and multilayer wraps for compression, offloaded using specialty half shoes and boots when we could get them for the patients, constructed “football” wraps from supplies in the clinic to pad and offload the forefoot, or otherwise used crutches or wheelchairs (we didn’t do casting back then). We debrided with fairly good regularity using disposable scalpels, but we still used reusable, stainless-steel curettes, forceps, and scissors that were sterilized each night. We were early adaptors of ultrasound therapy for debridement and had one of the first devices of that type in the region. We began using a wound-specific electronic documentation system in 2004, and for the first time were able to easily generate reports looking at time to healing, tracking of patient visits, and product utilization. With time and technology, newer advanced modalities began to emerge — and they haven’t stopped. Many new devices were variations of older items, but new devices brought better evidence and at least reasonable support for use of the product. As the years have raced past, this author’s locations of practice have changed (part-time status today), but the same group of practitioners has remained. There have been annual changes to the coding and coverage guidelines for what we do and what we use, changes that we had to be aware of, understand, and document appropriately. Today, life is no longer “simple.” The charges for products and procedures are bundled. Zip code can determine how and with what products patients are treated. In one state a certain CTP is covered for the entire body and in another it is only covered for use on the foot and leg. A couple of Medicare payers are looking to limit the number of debridements that any one patient can receive to a maximum of eight per year, when increasing evidence related to biofilm management and removal of senescent cells supports more debridements than that. Does that mean we stop doing debridements? Only if the driving force for the decision to debride is revenue. We are still going to do what is “right,” and wound management decisions should be made based on goals established by the evaluation of the patients and their wounds and knowledge of the barriers to healing that must be overcome. The bottom line is that providers have had to abide by the ever-changing rules of the HOPD for years while compliantly documenting justification for what was done both for the department as well as their own charges. But no one was really “minding the store.” Some used products and performed procedures “because they could” as many times as allowed “because they could.” The resulting costs, not just in wound care but in all of healthcare, have brought us to the place where we probably should be anyway: receiving payment based on doing the right thing at the right time for the right patient, and being able to show verification of quality care based on current evidence. We need to think of our patients as if they were our own mothers and fathers who are spending their own money for their care. Eligible providers are now on a track that will ultimately drive their payment system based on quality measures that are well known (or at least should be). HOPDs now have an opportunity and an obligation to create a system that drives and tracks quality care while ensuring that appropriate, evidence-based decisions are made and that treatment plans are executed to result in achieving the Triple Aim. It’s a no-brainer. That is what will equal success. 

How can HOPDs partner with providers to ensure that quality care can be quantified by wound care-specific quality measures? First, by providing the tools necessary in the form of an adequate, well-trained staff, the products necessary to provide needed disease-state support (eg, offloading and compression), topical products to meet the environmental needs of the wound, and advanced and active products, when needed, to change the healing trajectory. Second, and importantly, a documentation system that can track and report current acceptable measures to CMS and other payers, and taking the steps necessary to ensure their wound data is included in an appropriate registry, is incumbent among wound care professionals. How can HOPDs adapt? By accepting this changing paradigm. Ultimately, we are sure to be on a prospectively paid system to provide care to wound patients. Decisions for care will be made based on need and evidence-based practices in a timeframe that’s appropriate to each patient. “Chronicity” will be measured by patient and wound condition, not by time. An otherwise healthy patient who was injured or lives with a chronic wound will heal with good wound care based on removal of known local barriers to healing, whereas those who present with comorbid conditions that are known to have their healing impeded, either by themselves, their drugs, and/or their treatments, will be cared for with advanced products earlier. And the products that have proven over time to enhance wound healing in any one practitioner’s hands versus just the highest reimbursement will be utilized appropriately to mitigate potential complications such as infection or chronic inflammation and retarded healing. 

So, it becomes a win-win partnership, regardless of whether the provider is employed by the hospital or not. The rules of engagement are the same. HOPDs and physicians do not yet have government-sponsored wound care quality measures. These measures will become defined over time through benchmarking in one of the various wound care-specific data registries and will serve as guidance as we continue to provide quality care in a cost-effective manner with the end result being satisfied patients with closed wounds. Sound familiar? 

Lee C. Ruotsi is medical director at Catholic Health Advanced Wound Healing Centers and director of the wound care fellowship at Catholic Health System of Buffalo, NY. Dot Weir was on staff at Osceola Regional Medical Center, Kissimmee, FL, and Health Central Hospital, Ocoee, FL, and, at the time of publication, embarking on a new life in Buffalo, NY.

References

1. Longo MA. Examining the outpatient wound care nurse’s influence on the ‘triple aim’ initiative. TWC. 2016;10(7):14-5. 

2. Fife CE. From the editor. TWC. 2016;10(12):4.

3. Fife CE. The wound care clinician’s quality reporting survival guide. TWC. 2015;9(2):18-24.